The Promise & Responsibility of Focused Cardiac Ultrasound (FOCUS) in General Practice

Point-of-care ultrasound (POCUS) has been called “the new stethoscope.” And in many ways, that comparison is apt. Like the stethoscope, ultrasound places powerful diagnostic capability directly in clinicians’ hands, at the bedside, in the clinic, and in time-sensitive moments when rapid answers matter most.

But as a recent editorial in the European Heart Journal – Imaging Methods and Practice reminds us, the promise of FOCUS is matched by important pitfalls, especially when deployed by non-cardiology clinicians using hand-held ultrasound devices (HUDs).

For educators and institutions expanding ultrasound training across disciplines, the message is clear: access is not enough. Image acquisition and interpretation require structured training, deliberate practice, and oversight to ensure diagnostic integrity.

The Allure of Handheld Ultrasound

There is understandable enthusiasm for expanding cardiac ultrasound beyond the echocardiography lab. FOCUS and POCUS allow clinicians to:

• Rapidly assess cardiac function
• Evaluate suspected heart failure
• Perform bedside assessments without scheduling delays
• Extend diagnostic access in resource-limited settings

Modern HUDs now offer image quality sufficient for experts to accurately assess left ventricular size and function. That technological progress has removed one historical barrier.

But the critical question is no longer whether the device is capable. It is whether the operator is trained.

The Three Variables That Determine Accuracy

The article highlights three major factors that influence FOCUS accuracy:

1. Equipment
2. Image acquisition (operator skill)
3. Image interpretation (operator knowledge)

While handheld technology has matured significantly, diagnostic performance drops when image acquisition and interpretation are performed by clinicians with limited training.

In one referenced study, medical residents with a median experience of 27 exams showed strong correlation with experts when assessing global left ventricular function, but considerably weaker agreement when identifying regional dysfunction.

The implication? Basic findings may be attainable with modest training. Subtle or high-stakes pathology demands more.

Image Acquisition: The Often-Overlooked Skill

One of the most important takeaways from the editorial is that ultrasound competency has two distinct domains:

• Hand-eye coordination for image acquisition
• Clinical expertise for image interpretation

Cardiac sonographers may train for 6 months to 2 years, performing hundreds to thousands of scans solely to master acquisition. Cardiologists with advanced echocardiography certification interpret at least 750 studies.

By contrast, many international POCUS training courses range from 10 to 100 cardiac scans.

The editorial questions whether approximately 46 supervised exams, used in the referenced study of general practitioners, are sufficient to ensure diagnostic reliability.
The data suggest perhaps not.

Automation Is Not a Safety Net

Another striking finding: automated measurements such as auto-MAPSE and auto-ejection fraction did not improve diagnostic performance, and in some cases worsened it.

Automation remains dependent on image quality. If the acquisition is flawed, automated outputs may compound the error rather than correct it.

This reinforces a core principle in ultrasound education: software cannot compensate for suboptimal scanning technique. And this finding most likely applies double to AI interpretation which is so heavily discussed currently.

Telemedicine Overreads: A Practical Path Forward

Encouragingly, the strongest diagnostic performance occurred when expert telemedicine overreads were incorporated.

But, even then, limitations in image acquisition could not be fully overcome even though expert review improved overall diagnostic characteristics.

The article proposes a logical next step:

• Expand training focused specifically on image acquisition
• Emphasize technically challenging views (e.g., four-chamber view, mitral annulus)
• De-emphasize independent interpretation early on
• Incorporate routine expert overreads

One cardiology fellowship model described requires:

• A full month in the echocardiography lab
• Approximately 100 supervised scans
• Mandatory expert overread of every FOCUS study throughout training

This structured, layered approach maximizes safety while building competence.

What This Means for Ultrasound Education

As ultrasound expands into primary care, internal medicine, emergency medicine, and beyond, the conversation must shift from access to accountability.

The stethoscope analogy remains useful, but incomplete.

A novice can hear S1 and S2. Recognizing a diastolic rumble requires training. Similarly, obtaining a cardiac image is not equivalent to making a reliable diagnosis.

For institutions integrating cardiac POCUS into curricula, several principles emerge:

1. Prioritize Image Acquisition Mastery
   Repetition, simulation, and feedback are essential before diagnostic independence.

2. Incorporate Structured Oversight
   Tele-ultrasound and expert overreads can extend specialist expertise to frontline clinicians.

3. Recognize the Limits of Automation
   AI and auto-measurements are tools, but not substitutes for skill.

4. Define Competency Thresholds
   The field still lacks consensus on the minimum number of scans required for reliable performance. This remains an urgent research priority.

The Future: Democratized Imaging, Done Responsibly

Focused cardiac ultrasound represents a transformative opportunity to bring cardiac assessment closer to the patient. But expansion without rigor risks undermining trust in the modality.

The path forward is not retreat, but refinement:

• Stronger training frameworks
• Emphasis on acquisition quality
• Embedded expert oversight
• Longitudinal skill development

SonoSim provide an ecosystem of training tools and resources geared to enabling POCUS training at scale, while delivering on these fundamentals of repetitive acquisition and interpretation practice, in a simulated environment, but on real pathology. We see programs every day that leverage simulation in the right way to further training goals and advance learners of all levels to greater and greater levels of competency. This is particularly relevant in protocols like FOCUS where patients stand to gain the most if clinicians can efficiently and effectively leverage “the new stethoscope.”

References:

• Rhinehart, Z. & Sade, L. E. (2024). “The promise and pitfalls of focused cardiac ultrasound among general practitioners.” European Heart Journal – Imaging Methods and Practice, 2(1), qyae018.